INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on July 12, 2023 by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, Community Guidance Center was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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705.28 (d) (3) LICENSURE Fire safety.
705.28. Fire safety.
(d) Fire drills. The nonresidential facility shall:
(3) Ensure that all personnel on all shifts are trained to perform assigned tasks during emergencies.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report (SRFSR) and personnel records, the facility failed to ensure that all personnel on all shifts are trained to perform assigned task during emergencies.
Employee #4 was hired on November 2, 2022 as a counselor and was still in the position as of the date of the inspection. The training was completed on November 14, 2022.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
The employee will complete the fire safety on their first day at the home facility. It will be reviewed by the supervisor, director, and Quality officer to ensure that it is completed within the first 7 days of employment. |
709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on a review of client records, the facility failed to obtain a consent to release information form prior to releasing information in two out of seven records reviewed. There was no consent to release information forms for the funding source. Facility staff confirmed billing had occurred.
Client #4 was admitted on March 2, 2023 and was still active at the time of the inspection.
Client #5 was admitted on March 9, 2023 and was discharged on June 19, 2023.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Releases of information for funding sources will be obtained upon intake to the center. If there is an insurance change the finance department and director will notify the therapist in order to obtain a release of information for the funding source. Insurance reports will be run by the finance department and will notify the director regarding issues of insurance changes on a monthly basis to ensure appropriate releases. |
709.34 (a) (6) LICENSURE Reporting of unusual incidents
§ 709.34. Reporting of unusual incidents.
(a) The project shall develop and implement policies and procedures to respond to the following unusual incidents:
(6) Event at the facility requiring the presence of police, fire or ambulance personnel.
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Observations
Based on the review of the facility's policy and procedure manual, the facility failed to develop policies and procedures which included the response to an event at the facility requiring the presence of police, fire or ambulance personnel.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The policy of the Community Guidance Center involving critical incidents has been updated to reflect in events of emergency the facility will require the presence of police, fire, or ambulance. The policy had was updated on 7.26.2023. |
709.92(a) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
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Observations
Based on a review of client records, the facility failed to document a comprehensive treatment plan within guidelines established by the facility's policy and procedures manual in three out of seven applicable records reviewed. The facility's policy and procedures manual states the comprehensive treatment plan must be completed within 30 days following admission.
Client #4 was admitted on March 2, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was due no later than April 2, 2023; however, it was not completed until May 24, 2023.
Client #5 was admitted on March 9, 2023 and was discharged June 19, 2023. A comprehensive treatment plan was due no later April 9, 2023; however, it was not completed until May 24, 2023.
Client #7 was admitted on July 25, 2022 and discharged on January 6, 2023. A comprehensive treatment plan was due no later than August 25, 2022; however, it none was completed.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
The treatment plans are being audited monthly by supervisor, director, chief quality officer. Therapist will be completing treatment plans 7 days ahead of when they are expired. Therapist were informed of this on 7/14/2023 about the expectations for the service plans. |
709.92(a)(2) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of the client records, the facility failed to ensure that an individual treatment and rehabilitation plan shall be developed with the client. This plan shall include but not limited to, written documentation of type and frequency of treatment and rehabilitation services in two out of six client records reviewed.
Client #2 was admitted on February 7, 2023 and was still active at the time of the inspection. A comprehensive treatment plan was developed on February 19, 2023 with no type or frequency identified.
Client #6 was admitted on February 15, 2023 and discharged on April 18, 2023. A comprehensive treatment plan was developed on March 15, 2023 with no frequency identified.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The treatment plans are being audited monthly by supervisor, director, chief quality officer. Therapist will be completing treatment plans 7 days ahead of when they are expired. Supervisor and Director will review the type and frequency and sign off on the service plan. Therapist were informed of this on 7/14/2023 about the expectations for the service plans. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates within the regulatory timeframe in two out of four applicable records reviewed.
Client #2 was admitted on October 17, 2022 and was still active at the time of the inspection. A treatment plan update was completed on January 3, 2023 and an update was due no later than March 3, 2023; however, it was not completed until March 8, 2023.
Client #3 was admitted on August 12, 2022 and was discharged on March 28, 2023. A treatment plan update was completed on October 18, 2022 and the next update was due no later than December 18, 2022; however, it was not competed until December 22, 2022.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the July 14, 2022 licensing inspection.
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Plan of Correction
The treatment plans are being audited monthly by supervisor, director, chief quality officer. Therapist will be completing treatment plans 7 days ahead of when they are expired. Therapist were informed of this on 7/14/2023 about the expectations for the service plans. |
709.92(c) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(c) The project shall assure that counseling services are provided according to the individual treatment and rehabilitation plan.
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Observations
Based on a review of client records, the facility failed to ensure that the clients received counseling services according to their individual treatment plan in three out of seven applicable records reviewed.
Client #1 was admitted on April 10, 2023 and was still active at the time of the inspection. The treatment plan dated May 26, 2023 indicated one hour of individual sessions weekly. There was no documentation that the client received individual therapy between June 14 and July 3, 2023 and July 3-11, 2023.
Client #2 was admitted on February 7, 2023 and was still active at the time of the inspection. The treatment plan dated April 5, 2023 indicated weekly individual sessions. There was no documentation that the client received individual sessions between June 28 and July 11, 2023.
Client #7 was admitted on July 25, 2022 and was discharged on January 6, 2023. The treatment plan dated July 25, 2022 indicated individual sessions once weekly. There was no documentation that the client received individual therapy between October 27-Novemebr 17, and November 19-December 21, 2022.
These findings were reviewed with facility staff during the licensing inspection.
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Plan of Correction
Consumers will receive calls weekly to assure that appropriate services are provided in regards to the sessions as indicated on the treatment plan. Phone calls will be made by the admin secretary. Documentation will be made in the EHR regarding calls and voicemails. Therapist will review the treatment plan with the consumer and discuss appropriate time frames for care. If the consumer is unable to meet in the time frame a service plan update will occur. If no contact is made within the appropriate time frame a no contact letter will be sent out. D&A Supervisor, OP Director, Secretary Supervisor, and the Chief Quality Officer will review and monitor the EHR's to assure appropriate calls and follow up. |
709.93(a)(8) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to document a case consultation within guidelines established by the facility's policy and procedures manual in four out of six applicable records reviewed. The facility's policy and procedures manual states case consultations must be completed every 90 days following admission.
Client #1 was admitted on April 10, 2023 and was still active at the time of the inspection. A case consultation was due no later than July 10, 2023; however, none was completed.
Client #2 was admitted on admitted on February 7, 2023 and was still active at the time of the inspection. A case consultation was due no later than May 7, 2023; however, it was not completed until May 15, 2023
Client #5 was admitted on March 9, 2023 and was discharged on June 19, 2023. A case consultation was due no later than June 9, 2023; however, none was completed.
Client #7 was admitted on July 25, 2022 and was discharged on January 6, 2023. A case consultation was due no later than October 25, 2022; however, none was completed.
These findings were reviewed with facility staff during the licensing inspection.
This is a repeat citation from the July 14, 2022 licensing inspection.
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Plan of Correction
Case consults will be audited monthly by the supervisor, director, and chief quality officer. Therapist were informed that case consults will be completed with each treatment plan to assure accurate and timely feedback. Therapists were informed of this on 7/19/2023. |
709.93(a)(11) LICENSURE Client records
709.93. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to document follow up information within guidelines established by the facility's policy and procedures manual in two out of three applicable records reviewed. The facility's policy and procedures manual states the that follow up must be completed 30 days following discharge.
Client #6 was admitted on February 15, 2022 and discharged on April 18, 2023. A follow up was due no later than May 18, 2023; however, it was not completed until May 31, 2023.
Client #7 was admitted on July 25, 2022 and was discharged on January 6, 2023. A follow up was due no later than February 6, 2023; however, it was not completed until February 14, 2023.
These findings were reviewed with facility staff during the licensing process.
This is a repeat citation from the July 14, 2022 licensing inspection.
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Plan of Correction
The follow up report will be run weekly instead of bi-weekly to ensure follow-ups are being send within the 30 days. D&A Supervisor is going to track these. Correction of the report occurred on 7/26/2023. |